THE CONSUMER DISPUTES REDRESSAL FORUM, KOZHIKODE.
C.C. 438/2012
Dated this the 19th day of May 2017
(Smt. Rose Jose, B.Sc, LLB. : President)
Smt.Beena Joseph, M.A : Member
Sri. Joseph Mathew, MA, LLB : Member
ORDER
Present: Beena Joseph, Member:
This petition was filed on 11.10.2012. The case of the complainant is that they had joined a Mediclaim Insurance of opposite parties after remitting required premium, the mediclaim policy number was P/181311/01/2011/005522 the period of policy was 29.01.11 to 28.01.12 but the insurance policy and its schedule were not handed over in spite of repeated request and reminders. The 2nd complainant had taken the policy in the fond hope of protecting herself and the complainant from financial disaster in the unlikely event of suffering from any illness or disease which may require hospitalization and treatment.
As the first complainant experienced stomach pain, he was hospitalized on 12.01.12 and had to undergo surgery on 13.01.2012 for acute appendicitis from Nirmala Hospital, Calicut. The 1st complainant was an inpatient from 12.01.12 to 17.01.12. On 12.01.12 after the diagnosis that the complainant was suffering from appendicitis and for which surgery was required, the relative of the complainants informed the 2nd opposite party about the same and enquired about the procedures. The official of the 2nd opposite party informed that after discharge from the hospital they can submit the claim form with all treatment records and supporting bills for reimbursement as the hospitalization and treatment given to the complainant were covered under the mediclaim policy, the 1st complainant had duly submitted that the claim with all the relevant documents with the 2nd opposite party after discharging from the hospital. At the time of submitting the claim form, the officials of the 2nd opposite party informed the complainant number -1 to attach an explanation/excuse letter as well for condoning the delay in submitting the claim form that was the 1st time in the complainants were informed about the alleged delay in submission of the claim form. But the staff of the 2nd opposite party clarified the complainant that the claim will be settled at the earliest.
After a delay of around 3 months of the submission of the claim, the 1st opposite party had given a communication dated 10.03.12 and they repudiated the claim made by the 1st complainant on the alleged ground that under condition number 3& 4 no such exclusion clauses were ever brought to the notice of the complainant while taking policy or later. The allegations and claims seen made in the repudiation letter are not proper, correct or sustainable, besides being baseless. The opposite parties are not entitled to repudiate the claim that too for the alleged reasons stated therein.
The complainants had duly intimated the illness to the 2nd opposite party on 12.01.12 itself after diagnosing that he was suffering from acute appendicitis and surgery was necessary. The repudiation of the claim of the complainant No.1 that too for the alleged reason seen stated in the repudiation letter is not proper, correct, legal, fair or sustainable. The 1st opposite party was duly bound to refer the matter to the opinion of 2nd opposite party, or the 2nd opposite party ought to have submitted the true and correct facts to the 1st opposite party regarding the alleged delay caused or afford an opportunity to the complainant to state the true facts before a decision for repudiation could have been taken. The repudiation of the claim of the 1st complainant in such casual, indifferent and negligent manner is not proper, correct or legal, and is highly unbecoming on the part of an establishment like the opposite parties, which claim to be responsible and reputed.
In the above circumstances the complainant No.1 contacted the office of the 2nd opposite party many times, requesting them to review the decision to repudiate the claim and requiring them to settle the same at the earliest by paying the claim amount. After the repeated request and reminders the 1st opposite party had offered 50% of the claim amount. But the complainants were not ready to accept the same and required them to settle the total claim. Even though they have informed 1st complainant that they will sanction the claim after discussing with the 1st opposite party, till date they have not taken any steps for the redressal of the grievance of the complainants nor have shown the minimum courtesy of contacting the complainant even. Much loss, injury and hardship has been and is being caused and occasioned to the complainants on account of the negligence, deficiency in service and unfair trade practice on the part of the opposite parties. The complainants reasonably estimate a sum of Rs.1,00,000/- as compensation for loss, injury and damage sustained to him. Therefore complainants claims the treatment expense of Rs.24,965/- compensation for Rs.1,00,000/- for loss, injury and hardships on account of negligence and deficiency of service and unfair trade practice and pay the cost.
Notice issued to both parties, both of them appeared.
Opposite parties filed version stating the following facts. All the averments and allegations were denied except those that are specifically admitted by them. It is true that complainant had taken a mediclassic individual insurance policy from the opposite party for the period of 29.01.10 to 28.01.11 which has been further renewed up to 28.01.2012. The complainant was admitted on 12.01.12 at Nirmala hospital, Calicut for the treatment of acute appendicitis and discharged on 17.01.2012. it submitted that the intimation regarding hospitalization was received by opposite party only on 18.01.12 that is after a lapse of 7 days of occurrence of the event.
As per policy condition No.3 specifically states that “upon the happening of any event, which may give rise to a claim under this policy, notice with full particulars shall be send to the Company within 24 hours from the date of occurrence of the event”. This condition is a precedent to admission of liability under the policy. The company has been denied an opportunity to satisfy whether the person who underwent treatment is the same person who is covered under the policy. Since the complainant had not informed the hospitalization in time from the date of admission of, the claim falls outside the scope of the cover. It is true that complainant has submitted claim form with medical certificate, discharge summary bills and lab reports since the complainant has violated the policy conditions, which is precedent to admission of liability, the claim was rejected by the opposite party on the ground of violation of condition No.3 which was intimated to the complainant on 10.03.2012. The policy conditions clearly states that the liability under insurance is subject to the terms, conditions, Exclusion and definition. Moreover the policy schedule issued to the complainant clearly states about condition No.3. It is a settled law that terms of policy have to be construe as it is and the court cannot add or substract something beyond the policy terms and conditions.
The above complaint is filed vexatiously and frivously or harassing the opposite party for getting unlawful gain from the opposite party, who are dealing with public money under the guidelines of LRDA controlled by Govt. of India. As public money is held in trust, the company must exercise abundant caution in dealing with the claims by applying all conditions correctly. Opposite party have not caused any mental agony or suffering to the complainant at any point of time. Complainant is not entitled to get any relief prayed. The opposite parties were not committed deficiency of service or unfair trade practice as alleged. Hence the petition is liable to be dismissed.
Points to be considered.
- Is there any service deficiency or illegal trade practice adopted by opposite parties?
- Whether the repudiation of claim of opposite party is proper or not?
If yes what are the reliefs
In this matter complainant filed affidavit and examined as PW1, Ext.A1 to A5 marked. Ext.A1 is the original policy, Ext.A2 identity cards of complainants issued by opposite party, Ext.A3 Medical Bills, Ext.A4 Discharge summary, Ext.A5 repudiation letter. Opposite party filed affidavit and examined as RW1 Ext.B1 to B8 market. Ext.B1 is the original authorization letter, Ext.B2 proposal Form, Ext.B3 is the policy conditions, Ext.B4 is the policy copy, Ext.B5 is the original discharge summary of Nirmala hospital Ext.B6 is the request letter of the complainant to opposite party, Ext.B7 is the claim form, Ext.B8 is the repudiation letter.
The above complaint was filed against the repudiation of insurance claim of the complainant’s. In this juncture, it is to be noted that whether the complainant is having a valid policy. The complaint and version both the parties have no dispute regarding the existence of policy. The policy was having a coverage from 29.11.11 to 28.01.12. The alleged hospitalization was occurred on 12.01.12 at Nirmala hospital, Calicut. So it can be seen that the alleged incident was occurred during the insurance coverage period. The complainant herein was hospitalized from 12.01.12 to 17.01.12. Regarding this also there was no dispute. The medical certificates, discharge summary and medical bills also not disputed by the opposite party. The complainant herein states before this Forum that, they had intimated the event of hospitalization by the complainant to the opposite party No.2 as on 12.01.12 itself through telephone and the officials of the 2nd opposite party directed them to furnish claim form after discharge. So in this case it is seen that the complainant herein had submitted his claim form before the 2nd opposite party as on 18.01.12 which was not disputed by the opposite parties. On the other hand opposite party admitted in their version that, opposite party received claim form as on 18.01.12. Ext B6 is the condition letter obtained by the opposite party from the complainant was on 19.01.12, wherein it is stated that claim form was filed on 18.01.12. So the receipt of the claim form by the opposite party was on the next day of the discharge from the hospital. The Ext.B3 the policy condition clause 4(3) states that the claim must be filed within 15 days from the date of discharge from the hospital. So in this case the claim form was filed on the next day of discharge. So the condition No.4 (3) cannot be resorted to dismiss the claim by the opposite parties. The above condition includes which stating that “condition number 2,3 are precedent to admission of liability under the policy however the company will examine and relax the time limit mention in this condition depending upon the merits of the case.” Which shows that company has got a right to relax time limit according to the merit of the case.
In this matter company had obtained a condonation letter from the complainant which is stating reasons for non submission of claim in time. So it can be inferred that the above dismissal of condonation letter is improper,that too without applying mind. The main contention took by the opposite party in order to repudiate the claim is non intimation of hospitalization within 24 hours of the incident. And this is a precedent to admission of liability under the policy. But condition No.4 clause 3 notes, discards the defence put forwarded by the opposite party. From the discussion made above regarding the policy conditions. It can be seen that the repudiation of the claim by the opposite parties are unfair and illegal. So the action on the part of opposite parties is amounting to illegal trade practice and service deficiency. Moreover the conditions stated in Ext.B3 and Ext.A1 is not similar. Both of the conditions were not signed by any of the parties. So it cannot be treated as a binding agreement on the parties. We already find that the repudiation of policy is illegal so the petition is allowed.
Therefore we direct the opposite parties to pay Rs.24,965/- (Rupees twenty four thousand nine hundred and sixty five only)as the claim bill amount and Rs.5000/- (Rupees five thousand only)as compensation for deficiency in service and Rs.1000/-(Rupees one thousand only) as cost of the proceedings. Comply the order within one month from the date of receiving the copy of the order.
Dated this 19th day of May 2017.
Date of filing:11.10.2012.
SD/-MEMBER SD/- PRESIDENT SD/- MEMBER
APPENDIX
Documents exhibited for the complainant:
A1.Original policy issued by opposite party to the complainant
A2. Identity card of complainant issued by opposite party
A3.Medical bills(8 pages in series)
A4.Discharge summary of Nirmala Hospital
A5.Repudiation claim letter issued by opposite party dtd.10.03.2012.
Documents exhibited for the opposite party:
B1. Original Authorisation letter dtd.16.03.2016.
B2.Proposal form issued by opposite party dtd.29.01.10
B3 .Terms and conditions of the Medi classic Insurance policy
B4.Medi classic individual policy schedule
B5. Original Discharge Summary of Nirmala Hospital
B6.Request letter of the complainant to the opposite party dtd.19.01.12
B7.Claim Form for medical insurance
B8.Repudiation of claim letter
Witness examined for the complainant:
PW1. Joyce (complainant)
Witness examined for the opposite party:
RW1.Mridula, Madathil meethal, PO.Vengeri, Calicut.
Sd/-President
//True copy//
(Forwarded/By Order)
SENIOR SUPERINTENDENT
